Exhibit D
UNIVERSITY OF COLORADO DENVER
MEDICAL/SCIENTIFIC EQUIPMENT DISPOSAL REQUEST
Date: _____________________
Requesting Department
Requested by: _____________________________ (Electronic forwarding constitutes signature approval)
(Please Print)
Requestor’s Bldg/Room No._____________________________
Tele. No.______________________________
Chair/Director Approval (Required) ______________________________
(Please Print)
__________________________________________
Signature (Only for those not having access to e-mail)
Campus Box No. ________________
(Electronic forwarding constitutes signature approval)
__________________________________________
Signature (Only for those not having access to e-mail)
THIS DEPARTMENT HAS DETERMINED THE FOLLOWING MEDICAL/SCIENTIFIC EQUIPMENT IS NO LONGER NEEDED. PLEASE TAKE THE NECESSARY ACTION FOR ITS DISPOSAL.
PLEASE LIST EACH ITEM/COMPONENT SEPARATELY.
ONLY REQUIRED FOR CAPITAL EQUIPMENT
(Required)
(For HSD Use Only)
(For SAM Use Only)
FOPPS
Bldg / Room
#
UCD
I.D. No.
Acquisition
Date
Fund
Org
Program/Project
Acquisition
Cost
Description
Serial Number
Health &
Condition Safety Usage
Code
Code
Fac Ops Review
Required
HSD
Approval
Disposal
Code
Disposal
Number
NOTE: Items that have been exposed to infectious materials, radioactive isotopes, hazardous chemicals, or contain refrigerant (Freon) or oil must be inspected and properly Green Tagged by the Health and Safety Division.
Please use the Health and Safety Codes listed below to assist with this process.
USE THE FOLLOWING KEY TO DETERMINE THE CONDITION OF EACH ITEM:
A.
Item is in good and useable condition; minor cleaning may be required; parts and/or service are available.
B.
Useable after some minor repair, or partially useable with no repair; parts and/or service may not be available.
C.
Poor condition; requires major repair; there is questionable value in repairing the item.
D.
Very poor condition; it is believed the item should be scrapped.
SUBMIT TO: SAM.disposal@UCDenver.edu;EHS.Greentag@UCDenver.edu
(Electronic Submission Only)
fp1-02d
Revised 4/19/04
Health and Safety Usage Certification Key:
AA. Item has been exposed to infectious materials.
BB. Item has been exposed to radioactive isotopes.
CC. Item has been exposed to hazardous chemicals.
DD. Item contains refrigerant, oil or other materials.
EE. Item contains asbestos.
FF. Item has not been exposed to any of the above.